End-of-Life Care and the Elderly

End-of-Life Care and the Elderly

Death is more universal than life: everyone dies but not everyone lives.

A. Sachs

Every life ends with death. For the elderly, death is the end of a long life that has been shaped by personal history and world events, various relationships, well-set personality characteristics and, of course, happenstance. Each of these, in addition to the specific circumstances that herald death, shapes the experience of dying in old age. Unfortunately, the particularities of end-of-life care for the elderly are often overlooked. The specific challenges they face, the losses they incur, and the transitions they encounter can be difficult to address and often go unrecognized. As a consequence, their sense of dignity and quality of life may be undermined, and suffering mounts as life draws to a close.

CASE VIGNETTEProfessor M is a 78-year-old man with end-stage lung cancer. He had been a prominent university professor. His career had been marked by many successes and with the acknowledgments that often accompany outstanding achievement. As his illness progressed and he became more disabled, he found himself increasingly unable to maintain his usual work routine. His children had long since grown, and a close friend and colleague had recently passed away. In spite of his wife’s unwavering support and encouragement, he had become more and more despondent and withdrawn. While fully aware of the gravity of his medical condition, he found himself preoccupied with a lack of sense of purpose or meaning. In the face of such “emptiness,” while he was not actively suicidal, he indicated that life was beginning to feel rather pointless.

The principles of palliative carePalliative care is an approach that “improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychosocial, and spiritual problems.”1

The core principles of palliative care include a focus on the patient and the family; active management of distressing symptoms; total, individualized care of the patient; an interdisciplinary team approach; integration of the physical, psychological, and spiritual aspects of care; supporting family members throughout the patient’s illness and in their own bereavement; and offering support to the patient so that he or she may live as actively as possible until death.2,3

There is growing recognition that a palliative approach should be initiated as early as possible. This approach is meant to become more dominant as cure or life-sustaining options become less viable. For the elderly, palliation and therapeutic nihilism are not to be mistaken for one another. This can be problematic for vulnerable patients, including the elderly (Figure).4 Findings from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), for example, indicate that older age is associated with lower resource intensity and less aggressive treatment, including more decisions to withhold life-sustaining treatment.5

There is also evidence that older adults are less likely to receive adequate pain management and are less likely to be referred for palliative care services.6-8 For marginalized populations, comfort measures are sometimes misconstrued as a substitute for other health care options.4 Palliative care is not about giving up; rather, palliative care is about never shirking responsibility to assuage patient distress and suffering. As such, it should be integrated in a seamless way with all treatment services for the elderly. It should be an integral part of geriatric medicine, which strives to provide the best possible quality of life for, and to meet the unique needs of, older adults and their families.